Multi-ligament injury of the knee

Case contributed by Dr Joachim Feger

Presentation

Knee twisting injury accompanied by a pop during a volleyball game.

Patient Data

Age: 15 years
Gender: Female

Findings:

Extensive knee joint effusion

Intercondylar region:

  • abnormal orientation, disruption and discontinuity of the anterior cruciate ligament (ACL) fibers
  • focal fluid visible between the anterior cruciate ligament and the lateral femoral condyle in the intercondylar notch

Medial compartment:

Lateral compartment:

  • bone contusions at condylopatellar sulcus of the lateral femoral condyle and the posterior lateral tibial plateau
  • unremarkable cartilage and lateral meniscus 
  • visible Wrisberg meniscofemoral ligament with a Wrisberg pseudo-tear
  • anterior and posterior, inferior popliteomeniscal fascicles not readily definable and small lesion of the lateral aspect of the superior popliteomeniscal fascicle

Patellofemoral compartment:

Impression:

  1. rupture / high-grade tear of the anterior cruciate ligament with bone bruises at typical locations
  2. partial tear of the medial collateral ligament
  3. low-grade posteromedial corner injury
  4. partial medial patellofemoral ligament tear of the femoral origin
  5. a suspected small tear of the popliteomeniscal fascicles
  6. extensive knee joint effusion

 

Annotated image

Anterior cruciate ligament tear:

  • abnormal orientation, disruption and discontinuity of the anterior cruciate ligament (ACL) fibers (red arrows)
  • focal fluid visible between the anterior cruciate ligament and the lateral femoral condyle in the intercondylar notch also referred to as the empty notch sign (red arrowhead)
  • bone contusions at the condylopatellar sulcus also known as deep lateral femoral notch sign (orange arrow) and at the posteromedial and posterolateral tibial Plateau (orange arrowheads) as an expression of a pivot-shift injury

Associated injuries:

  • tearing of the anterior part of the joint capsule and the femoral portion of the medial meniscocapsular ligament (blue arrow)
  • tearing of the posterior oblique ligament (blue arrowhead) 
  • sprain of the tibial semimembranosus tendon insertion (purple arrowhead)
  • a small longitudinal meniscal tear of the posterolateral border of the lateral meniscus at the insertion of the posterosuperior meniscopopliteal fascicle (purple arrow)

Case Discussion

This case illustrates MRI findings in multi-ligament knee injury:

The patient was treated with bracing for 6 weeks and delayed anterior cruciate ligament reconstruction. The medial ligamentous structures were after those 6 weeks intraoperatively stable and not further inspected. The small longitudinal meniscal tear of the posterolateral border of the lateral meniscus at the insertion of the posterosuperior meniscopopliteal fascicle was confirmed and repaired.

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